Essay: Contrast between high cost of hospital care and the wish to die at home should make us pause

Kimberlyn McGrail, PhD, is an assistant professor at the University of B.C., associate director of the UBC Centre for Health Services and Policy Research, a senior researcher with Statistics Canada and an associate with the Centre for Clinical Epidemiology and Evaluation.Photo by
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Getting older often means needing more health care. It is precisely this relationship between age and need that creates boomerangst: the fear that the boomers are going to bankrupt our health-care system.

This fear is out of proportion to reality, for two reasons. First, study after study in Canada and elsewhere over the past 30 years shows that population aging adds a small and predictable amount of pressure on the health-care system each year. It is one of the least important among the many different cost drivers in the health-care system. Increasing use of laboratory testing and imaging, for example, adds twice as much in costs each year to physician services than does aging.

Second, how close people are to death is far more related to their use of health-care services than is their age. Studies from the U.S. show that the five per cent of Medicare (over age 65) recipients who die each year consistently account for 25 to 30 per cent of all Medicare spending. A recent study in B.C. showed that average spending on health-care services is six times higher for older people who die in the year (about $36,000) compared to older people who survive (about $6,000). Half of the spending for people who die is for acute hospital care.

Most deaths, particularly at older ages, are related to frailty or chronic disease, which means that many, if not most, are in some sense expected. When asked, the vast majority of people — some estimates are as high as 90 per cent — say they would wish to die at home. Yet fewer than half actually do so.

The contrast between high end-of-life health-care spending — often in hospital — and the wish to die at home should make us pause. Are people getting what they want? Are they proceeding on the journey toward the end of life as they desire? The experience of LaCrosse, Wisconsin, suggests the answer is “No.”

Nearly everyone who lives in LaCrosse has an end-of-life care plan, meaning simply that they have discussed their wishes with family members and/or friends and, where appropriate, with their physician. LaCrosse also has one of the lowest health-care spending rates for end-of-life care in the U.S.

Curtailing spending was not the objective of the push for advanced care planning in LaCrosse — the goal was to give patients the care they wanted. The experience in LaCrosse suggests that when discussions take place and individuals make explicit choices about the types of care they do and do not want to receive, they receive fewer and less intense services than they would otherwise be provided. They are more satisfied with their care, and so are the people who love and care for them.

New regulations on advance care planning came into effect on Sept. 1 in B.C. These regulations are meant to provide more clarity and more flexibility to making your wishes known and ensuring that they will be followed. Health authorities all provide resources to help people start conversations and articulate their plans; Fraser Health is considered a national leader in this area. There is a national movement called “Speak Up” that provides resources to help individuals and communities help get the conversation started.

Ultimately, the key is the conversation that people need to have in their own families about their wishes. All of us will die — that is beyond our control. But we can and should hope to have a say in how we die and, if we are lucky, when. Everyone’s choices will not be the same.

Have the conversation. Make yours known, and know the wishes of your loved ones.

Kimberlyn McGrail, PhD, is an assistant professor at the University of British Columbia, associate director of the UBC Centre for Health Services and Policy Research, a senior researcher with Statistics Canada and an associate with the Centre for Clinical Epidemiology and Evaluation. Kim’s current research interests are in variations in health-care-services use and outcomes, aging and the use of health-care services, and understanding health care as a determinant of health. She has collaborated in provincial and federal policy and with decision-makers, including the B.C. Ministry of Health Services, the Health Council of Canada and the Canadian Institute for Health Information. Kim was the 2009-2010 Commonwealth Fund Harkness Associate in Health Care Policy and Practice. She holds a PhD in health care and epidemiology from UBC and a Master’s in public health from the University of Michigan.

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